Provider Demographics
NPI:1568005338
Name:LIFE CARE & WISDOM CENTER PERSONAL CARE HOME
Entity Type:Organization
Organization Name:LIFE CARE & WISDOM CENTER PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FLOYD
Authorized Official - Middle Name:
Authorized Official - Last Name:BILLUPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-256-0698
Mailing Address - Street 1:4515 SUNLIGHT CT
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-4585
Mailing Address - Country:US
Mailing Address - Phone:708-256-0698
Mailing Address - Fax:
Practice Address - Street 1:5637 LA FLEUR TRL
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2846
Practice Address - Country:US
Practice Address - Phone:708-256-0698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GABL19-000371OtherBUSINESS LICENSE